Questioning Common Nursing Practices: What Does the Evidence Show? to Improve Patient Outcomes, Nurses Need to Challenge Practice Traditions

TO MEET THE NEEDS of patients and their families, healthcare practice must be based on current research and the best evidence. Many definitions of evidence-based practice (EBP) exist. All share similar elements--critical review of current research and examination of other forms of evidence, including national and local guidelines for practice, practice consensus documents, benchmark data, quality improvement studies, and population or patient perspectives.

To embrace EBP, nurses must critically examine multiple forms of evidence. No longer is it acceptable to resist changing a practice simply because the task or skill in question "has always been done that way." To move nursing practice forward, we must question practices and continually review available evidence to ensure a given practice benefits patients. By doing this, nurses can lead healthcare reform through embracing EBP that results in better care. This article discusses the evidence on several common nursing practices and makes recommendations to help improve outcomes.

Assessing pain in nonverbal adults

Pain is a subjective experience, defined by whatever the patient says it is and existing whenever the patient says it exists. It's best assessed by patient self-report, which clinicians should elicit routinely and repeatedly, and then implement appropriate interventions.

Assessing and managing pain is a nursing care priority for all patients--even those who can't communicate verbally. Obvious challenges arise when a patient can't give a self-report due to severe illness, altered cognition, or use of equipment (such as a mechanical ventilator) that inhibits communication. We now have a large body of evidence to guide nursing management of pain, including pain in nonverbal adults. To meet the pain-management needs of nonverbal adults, assess frequently for behavioral changes, anticipate pain after certain procedures, use patient surrogate reporting, and administer analgesic trials (and evaluate the patient's response).

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Current evidence shows the most effective way to assess nonverbal adults for pain is to follow an evaluation hierarchy. (See Hierarchy of pain assessment techniques). In nonverbal patients, pain assessment relies less on vital-sign assessment and more on observing behaviors, checking for potential causes of pain, and eliciting information from the patient's surrogates. Vital-sign changes are misleading as a primary indicator of pain because they may stem from underlying physiologic conditions, hemodynamic changes, and medications. Only limited evidence suggests vital-sign assessment alone should be used to gauge pain. Nonetheless, vital-sign changes may suggest the need for further assessment for pain or other stressors. More importantly, absence of vital-sign changes doesn't indicate absence of pain.

You can use several valid and reliable observational and behavioral scales to aid pain assessment in nonverbal patients. But be aware that these scales don't evaluate pain intensity, especially in patients receiving sedatives. Patients with advanced dementia require additional behavioral observation. As dementia progresses, self-reporting ability decreases. EBP suggests nurses should assess for pain and intervene appropriately in patients (including dementia patients) with conditions that typically cause pain, such as chronic arthritis, low back pain, and neuropathies. Pain-related behaviors or indicators may include changes in facial expression, verbalizations and vocalizations, changes in activity patterns or routines, rubbing a body part, and altered interpersonal interactions (such as agitation, restlessness, and combativeness). The City of Hope Pain and Palliative Care Resource Center offers a comprehensive list of resources and valid, reliable tools for assessing pain in elderly patients with cognitive impairment. (Visit http://prc.coh.org/pain_assessment.asp. …

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